We carried out an announced comprehensive inspection at Hatfield Road Surgery on 19 September 2017. Overall the practice was rated as good. However, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided well-led services. Consequently the practice was rated as requires improvement for providing well-led services. The full comprehensive report on the September 2017 inspection can be found by selecting the ‘all reports’ link for Hatfield Road Surgery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 4 April 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches of regulation that we identified in our previous inspection on 19 September 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
On this focused inspection we found that the practice had made improvements since our previous inspection and were now meeting the regulation that had previously been breached.
The practice is now rated as good for providing well-led services.
Our key finding was as follows:
- There were effective governance arrangements in place to ensure complaints were managed in accordance with the practice’s policy and procedure and the absence of a defibrillator was appropriately risk assessed.
Additionally where we previously told the practice they should make improvements our key findings were as follows:
- The practice kept a record of fire drills. We saw that the fire drill completed in January 2018 had been documented. This included a record of how many staff and patients were involved, the time taken by them to evacuate the building and that all employees and visitors were accounted for during a roll call among other things. The record showed that no further action was required as a result of the drill as all staff had correctly followed procedure and the alarm system worked as it should.
- Following our inspection in September 2017 the practice had reviewed and updated its business continuity plan. We saw the plan now contained details of how the practice would respond to any loss of premises, power, telephones and medical records among other things. This included an arrangement for the temporary use of space at another local practice in an emergency situation. We saw the plan contained up-to-date contact details for all staff at the practice along with those of service providers such as utility companies. From our conversations with staff we found that both GP partners and the practice manager kept a copy of the plan off-site should the practice be inaccessible in an emergency situation.
- The practice discussed the below average uptake among its patient population for some nationally run and managed cancer screening programmes. The staff we spoke with demonstrated an understanding of the cultural sensibilities to such programmes displayed by some of its patient population. There was evidence to suggest the practice responded to those sensibilities and encouraged its relevant patients to engage with them and attend for screening. For example, between them the GPs at the practice could offer consultations in languages other than English including Bengali, Hindi and Urdu. Many of the practice’s patients with English as a second language could be informed about and encouraged to attend the cancer screening programmes by the GPs in their first language during consultations. We saw the practice acted on information it received from NHS England about patients who had not responded to their invitations to participate in the bowel cancer screening programme. Between 1 April 2017 and 31 March 2018 the practice wrote to 98 such patients encouraging them to participate. We noted the letters were always sent in English but at the time of our inspection the practice was considering sending translated versions of the letter for the relevant patients.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice